Healthcare Provider Details

I. General information

NPI: 1770576704
Provider Name (Legal Business Name): DEBORAH LYNNE SIDERS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: DEBORAH LYNNE SIDERS CRNA

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HOSPITAL AVE
JEFFERSON NC
28640-9244
US

IV. Provider business mailing address

629 FAIRWAY RIDGE DR
WEST JEFFERSON NC
28694-8394
US

V. Phone/Fax

Practice location:
  • Phone: 336-846-7101
  • Fax:
Mailing address:
  • Phone: 336-877-3376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number193584
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: